Search

Purpose The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures. Methods Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval. Results A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85). Conclusions There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data. Clinical relevance Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

This study evaluated the influence of fracture obliquity and locking screw configuration on interfragmentary motion during torsional loading of distal metaphyseal tibial fractures fixed by intramedullary (IM) nailing. The stability of six IM nail locking screw configurations used to fix distal metaphyseal tibial fractures of various obliquities was evaluated. A coronal osteotomy from proximal lateral to distal medial was made in sawbone tibiae at different obliquities from 0° to 60°. After fixation, motion at the fracture was assessed during internal and external rotation tests to 7 Nm under two compressive loading conditions: 20 N and 500 N. With results organized by interlocking configuration, significant differences in interfragmentary rotation between fracture obliquities are observed when the number of interlocking screws is decreased to one distal static and one proximal dynamic during internal rotation. During external rotation testing, significant rotational differences between fracture obliquities are encountered with two distal static screws and one proximal dynamic. No significant differences were seen between different distal interlocking screw orientations (two parallel versus perpendicular distal screws) for all fracture obliquity patterns tested. Fracture obliquity influences rotational stability which can be mitigated by interlocking screw configurations when nailing distal tibia fractures. At least two distal and one proximal interlocking screw in a static mode is recommended to resist torsional loading of distal tibia fractures undergoing intramedullary nailing. The addition of more interlocking screws than this did not significantly alter control of torsional displacement with load.

Modular femoral stem provides flexibility in femoral reconstruction, ensuring improved "fit and fill". However, there are risks of junction failure and corrosion, as well as cost concerns in the use of modular femoral stems.We reviewed prospectively-gathered clinical and radiographic data on revision total hip arthroplasties (THAs) performed from 2001-2007 using modular, cementless femoral component performed by the 2 senior authors. Patients with a minimum follow-up of 7 years were included in this study.Sixty-four patients (68 hips) with a median age of 68 ± 14 years (range 40-92 years) at revision THA were included. The median follow-up was 11.0 ± 1.8 years (range 7-14). Harris hip score, femoral stem subsidence, and stem osseointegration were recorded. The Harris hip score improved from an average of 38.1-80.1 (P.01). Five hips had one or more dislocations. Seven patients underwent reoperations, 3 of which did not involve the stem. Four stems required revision because of infection, recurrent dislocation, or suboptimal implant position. Survival rates for any reasons and revision for femoral stems were 90% and 94%, respectively, at the most recent follow-up. Four stems subsided more than 5 mm, but established stable osseointegration thereafter. Seven nonloose stems (10.2%) demonstrated radiolucent lines in Gruen zones 1 and 7. No complications regarding the modular junction were encountered.Modular, cementless, extensively porous-coated femoral components have demonstrated intermediate-term clinical and radiographic success. Initial distal intramedullary fixation ensures stability, and proximal modularity further maximizes fit and fill.

The indications for the use of intramedullary (IM) nails have been extended to include extra-articular distal metaphyseal tibia fractures. We hypothesize that interfragmentary motion during physiologic compressive loading of distal tibia fractures is influenced by fracture obliquity and can be modulated by interlocking screw configuration. Sawbone specimens were osteotomized with frontal plane obliquities ranging from 0° to 60° and then fixed by IM nailing with six interlocking screw configurations. Interfragmentary motion was evaluated during loading in axial compression to 1000 N. Comparisons of interfragmentary motions were made (1) between configurations for the various fracture obliquities and (2) between fracture obliquities for the various screw configurations using a mixed-effects regression model. As the degree of fracture obliquity increased, significantly more interfragmentary displacement was shown in configurations with two distal interlocking screws and one proximal screw set in dynamic mode. Fracture obliquity beyond 30° causes demonstrated instability in configurations with less than two distal locking screws and one proximal locking screw. Optimizing the available screw configurations can minimize fracture site motion and shear in distal tibial fractures with larger fracture obliquities.

Purpose The use of routine physical therapy (PT) and occupational therapy (OT) after certain hand procedures, such as carpal tunnel release, remains controversial. The objective of this study was to evaluate baseline use, the change in use, variation in prescribing patterns by region, and costs for PT/OT after common hand procedures. Methods Outpatient administrative claims data from patients who underwent procedures for carpal tunnel syndrome, trigger finger, carpometacarpal arthritis, de Quervain tenosynovitis, wrist ganglion cyst, and distal radius fracture were abstracted from the Truven Health MarketScan database from 2007 to 2015. The incidence of therapy and total reimbursement of therapy per patient were collected for each procedure over a 90-day postoperative observational period. Trends in use of therapy over time were described with average compound annual growth rates (CAGRs), a way of quantifying average growth over a specified observation period. Variations in the incidence of PT/OT use across 4 census regions were assessed. Results The incidence of 90-day utilization of PT and OT after hand procedures was 14.0% and increased for all procedures during the observation period with an average CAGR of 8.3%. Cost per therapy visit was relatively stable when adjusted for inflation, with an average CAGR of 0.63%. Patients in the northeast had a significantly higher incidence of PT/OT use than those in the south and west for all procedures except carpometacarpal arthritis. Conclusions Use of PT and OT has increased over time after common hand procedures. Geographical variation in the utilization rate of these services is substantial. Limiting unwarranted variation of care is a health policy strategy for increasing value of care. Type of study/level of evidence Outcomes Research II.

Background This study evaluated patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability. Methods Dislocation and nondislocation cohorts were established for analysis in 119 patients who had undergone RTSA at our institution between 2011 and 2014. Preoperative history and parameters pertaining to RTSA design were evaluated for correlation with instability. A logistic regression model was used to analyze independent predictors. Results Eleven patients (9.2%) demonstrated instability in the early postoperative period. Dislocations occurred at an average of 8 weeks postoperatively (range, 3 days-5 months). The mean follow-up of all patients was 28 months (range, 6-106 months). Postoperative instability was associated with male gender, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability. In addition, 5 of the 11 patients (45%) in the instability cohort sustained a second dislocation requiring another operation. Conclusions Redislocation after revision surgery for the initial dislocation was an unexpected and alarming finding. Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of patients of our cohort and required another revision with a larger glenosphere and thicker humeral inserts. Initial instability after RTSA must be carefully managed, especially in the revision and post-traumatic setting. Exchange to a thicker polyethylene insert only carries a higher risk of recurrent instability.

Purpose Rising costs at the patient level have been recognized and shown to directly influence patient decisions. By understanding patient interests in discussing cost, hand surgeons may better prepare themselves and their practices to communicate costs with patients. Methods We surveyed 128 patients at an upper extremity surgery clinic at their 2-week postoperative visit. Survey domains included basic patient demographics and an assessment of patient financial distress, along with questions that rated patient interest with patient-physician financial conversations. These factors included patients' desire for a conversation regarding cost, whether or not patients have discussed cost with their surgeon, barriers to these discussions, and overall views concerning cost containment in hand care. Results Seven percent of patients discussed the costs of their surgical care with their physician. Eleven percent of patients reported that a doctor should not discuss the costs of their surgical care. Forty-eight percent of patients reported that a doctor should initiate a conversation regarding costs of care when a new treatment is being considered. Fifty-nine percent of patients agreed that physicians should consider the amount of money a patient will have to pay when choosing a new treatment. Conclusions Patients can experience financial hardship as a result of their surgery and some patients are interested in discussing costs with their doctor. Patients indicated that doctors should be concerned with lowering the costs of surgery and should initiate a conversation regarding costs of care when a new treatment is being considered. Clinical relevance Patients are interested in a conversation regarding their cost of hand surgery care. Making cost data more transparent and available to physicians and patients may facilitate communication regarding cost of care.